MEDICARE: GOLDEN DIVERSIFIED SERVICE INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	310400000X	Assisted Living Facility	5433	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1417381757
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GOLDEN DIVERSIFIED SERVICE INC

Provider Business Mailing Address
First Line	:	809 NE 20TH AVE
Second Line	:
City	:	FORT LAUDERDALE
State	:	FL
Zip	:	33304-3035
Country	:	US
Telephone Number	:	954-524-6054
Fax Number	:	954-525-6868

Provider Business Practice Location Address
First Line	:	809 NE 20TH AVE
Second Line	:
City	:	FORT LAUDERDALE
State	:	FL
Zip	:	33304-3035
Country	:	US
Telephone Number	:	954-524-6054
Fax Number	:	954-525-6868

Authorized Official
Title or Position	:	OWNER
Name	:	SWABY A KERR ROLLE
Credential	:
Telephone Number	:	954-524-6054

Provider Enumeration Date	:	08/22/2013
Last Update Date	:	08/22/2013

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